Kavitha Ramchandran

Clinical Assistant Professor, Medicine - Oncology

Bio

Bio

Kavitha Ramchandran MD, graduated with an undergraduate degree in Human Biology from Stanford University, did medical school and residency training in medicine at University of California, San Francisco and completed her fellowship in Medical Oncology and Palliative Medicine at Northwestern University, Chicago. She joined faculty at Stanford University in 2007. Currently she is a Clinical Assistant Professor of Medicine in the Division of Oncology and Division of General Medical Disciplines.

Dr. Ramchandran is recognized for her contributions as a leader in the integration of palliative and oncology care. Dr. Ramchandran is one of a small number of dual trained faculty who are working to build synergies between the fields of oncology and palliative medicine in the areas of supportive care research, and novel models of care. She now serves as Stanford Cancer Institute’s Transformation Design lead for improving the palliative care experience for patients with a cancer diagnosis. She is also the Medical Director of Palliative Medicine at Stanford Cancer Institute.

In her care of patients Dr. Ramchandran values a deep relationship with the families she cares for. She provides care that is aligned with the patient and family's personal values with the goal of the best quality of life possible.

Dr. Ramchandran’s research focuses on developing care delivery models that incorporate values (patients, family members, and clinicians), as well as novel means of palliative care education. She also is part of an active thoracic oncology trials group recruiting patients for clinical trials using novel therapeutics.

Dr. Ramchandran currently serves on the Patient and Survivor Care Committee for the American Society of Clinical Oncology and the National Comprehensive Cancer Network Palliative Care task force. She serves as a clinician in thoracic oncology and in palliative medicine at Stanford Cancer Institute.

Links

Research & Scholarship

Current Research and Scholarly Interests

My research focuses on innovative models of care delivey to understand how to integrate primary and specialist palliative care. We also do work in palliative care education and how to scale our education to be impactful and sustainable. We are evaluating online models.

In cancer care I do research on novel therapeutics in thoracic malignancies including immunotherapy, new targeted agents, and new sequencing of approved drugs.

Genetic Testing in Screening Patients With Stage IB-IIIA Non-Small Cell Lung Cancer That Has Been or Will Be Removed by Surgery (The ALCHEMIST Screening Trial)Recruiting

This research trial studies genetic testing in screening patients with stage IB-IIIA
non-small cell lung cancer that has been or will be removed by surgery. Studying the genes
in a patient's tumor cells may help doctors select the best treatment for patients that have
certain genetic changes.

A single-arm, open-label, multicenter, phase II study. Treatment with LDK378 750 mg qd will
continue until the patient experiences unacceptable toxicity that precludes further
treatment, discontinues treatment at the discretion of the investigator or patient, starts a
new anti-cancer therapy and/or dies. LDK378 may be continued beyond RECIST-defined PD as
assessed by the investigator if, in the judgment of the investigator, there is evidence of
clinical benefit. In these patients tumor assessment should continue as per the schedule of
assessments until treatment with LDK378 is permanently discontinued. Patients who
discontinue the study medication in the absence of progression will continue to be followed
for tumor assessment until the time of PD as assessed by the investigator

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie San Pedro-Salcedo , 650-724-1388.

A Study of Onartuzumab (MetMAb) in Combination With Bevacizumab (Avastin) Plus Platinum And Paclitaxel or With Pemetrexed Plus Platinum in Patients With Non-Squamous Non-Small Cell Lung CancerNot Recruiting

This multicenter, randomized, double-blind, placebo-controlled study will evaluate the
efficacy and safety of RO5490258 (MetMab) in combination with either of two backbone
chemotherapy regimens in the first-line setting in patients with incurable Stage IIIB or IV
non-squamous non-small cell lung cancer. In Cohort 1, patients will be randomized to receive
4 cycles of bevacizumab (Avastin) 15 mg/kg iv, paclitaxel 200 mg/m2 iv, platinum
(cisplatin/carboplatin) iv plus either MetMab 15 mg/kg iv or placebo on Day 1 of each 21-day
cycle. In Cohort 2, patients will be randomized to receive pemetrexed 500 mg/m2 iv, platinum
(cisplatin/carboplatin) iv plus either MetMAb 15 mg/m2 iv or placebo on Day 1 of each 21-day
cycle. Patients who have not progressed after 4 cycles will be offered maintenance therapy
with their assigned treatment of bevacizumab plus either MetMAb or placebo (Cohort 1) or
pemetrexed plus either MetMAb or placebo (Cohort 2). Anticipated time on study treatment is
until disease progression or unacceptable toxicity occurs.

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie SanPedro-Salcedo, (650) 724 - 1388.

Rociletinib is a novel, potent, small molecule irreversible tyrosine kinase inhibitor (TKI)
that selectively targets mutant forms of the epidermal growth factor receptor (EGFR) while
sparing wild-type (WT) EGFR. The purpose of the study is to evaluate the pharmacokinetic
(PK) and safety profile of oral rociletinib; to determine the maximum tolerated dose (MTD)
and/or recommended Phase 2 dose (RP2D) of oral rociletinib; to assess the safety and
efficacy of rociletinib in previously treated NSCLC patients known to have the T790M EGFR
mutation.

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie San Pedro Salcedo, 650-724-1388.

RATIONALE: Manuka honey may prevent or reduce esophagitis-related pain caused by
chemotherapy and radiation therapy. It is not yet known whether Manuka honey is more
effective than standard care in preventing pain.
PURPOSE: This randomized phase II clinical trial is studying Manuka honey to see how well it
works in preventing esophagitis-related pain in patients receiving chemotherapy and
radiation therapy for lung cancer.

Stanford is currently not accepting patients for this trial.For more information, please contact Laura Gable, (650) 736 - 0798.

A Phase II Study to Evaluate the Efficacy and Safety of Oral Ceritinib in Patients With ALK-positive NSCLC Metastatic to the Brain and/or to LeptomeningesRecruiting

This is a phase II, multi-center, open-label, five-arm study in which the efficacy and
safety of oral ceritinib treatment will be assessed in patients with NSCLC metastatic to the
brain and/or to leptomeninges harboring a confirmed ALK rearrangement, using the FDA
approved Vysis ALK Break Apart FISH Probe Kit (Abbott Molecular Inc.) test and scoring
algorithm (including positivity criteria). If documentation of ALK rearrangement as
described above is not locally available, a test to confirm ALK rearrangement must be
performed by a Novartis designated central laboratory. Patients must wait for the central
laboratory result of the ALK rearrangement status before initiating treatment with
ceritinib.

RATIONALE: Radiation therapy uses high energy x-rays to kill tumor cells. This may be an
effective treatment for extensive stage small cell lung cancer.
PURPOSE: This randomized phase II trial is comparing how well radiation therapy to the brain
works when given with or without radiation therapy to other areas of the body in treating
patients with extensive stage small cell lung cancer.

Stanford is currently not accepting patients for this trial.For more information, please contact Laura Gable, (650) 736 - 0798.

Talactoferrin in Treating Patients With Relapsed or Refractory Non-Small Cell Lung Cancer or Squamous Cell Head and Neck CancerNot Recruiting

This phase I trial studies how well talactoferrin works in treating patients with relapsed
or refractory non-small cell lung cancer (NSCLC) or squamous cell head and neck cancer.
Biological therapies, such as talactoferrin, may stimulate the immune system in different
ways and stop tumor cells from growing

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie San Pedro-Salcedo, (650) 724 - 1388.

This multicenter, randomized, double-blind, placebo-controlled study will evaluate the
efficacy and safety of onartuzumab (MetMAb) in combination with paclitaxel plus platinum in
patients with incurable Stage IIIB or Stage IV squamous non-small cell lung cancer (NSCLC).
Patients will be randomized to receive either onartuzumab (MetMAb) 15 mg/kg iv or placebo on
Day 1 of each 21-day cycle in combination with 4 cycles of paclitaxel 200 mg/m2 iv and
platinum (carboplatin/cisplatin) iv on Day 1 of each 21-day cycle. Patients who have not
progressed after 4 cycles will continue with either onartuzumab (MetMAb) or placebo as
maintenance therapy until disease progression or unacceptable toxicity occurs.

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie San Pedro-Salcedo, (650) 724 - 1388.

This phase II trial studies how well pegylated irinotecan NKTR 102 works in treating
patients with non-small cell lung cancer, small cell lung cancer, or breast cancer that has
spread to the brain and does not respond to treatment. Pegylated irinotecan NKTR 102 may
stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

Erlotinib With or Without Hydroxychloroquine in Chemo-Naive Advanced NSCLC and (EGFR) MutationsNot Recruiting

The purpose of this research study is to learn if adding hydroxychloroquine (HCQ) to
erlotinib helps treat non-small cell lung cancer (NSCLC). Another goal of this research
study is to learn more about NSCLC and how it may respond to study treatment. Erlotinib
(Tarceva) is a type of drug called a tyrosine kinase inhibitor (TKI). TKIs block a protein
called the epidermal growth factor receptor (EGFR). EGFR may control tumor growth and tumor
cell survival. However, although TKI drugs can work for some lung cancer patients for a
period of time, eventually the tumor finds a way to resist or counteract the TKI treatment
and it begins to grow again. Hydroxychloroquine (HCQ) is a drug approved by the FDA for
treating malaria, rheumatoid arthritis, and several other diseases. Laboratory research
suggests that when HCQ is given with a TKI, it may help delay or prevent TKI resistance from
developing.

Stanford is currently not accepting patients for this trial.For more information, please contact Zeina Babetty, (650) 723 - 2983.

Erlotinib in Patients With Resected, Early Stage NSCLC With Confirmed Mutations in the EGFRNot Recruiting

In this research study erlotinib will be given to eligible participants whose lung cancer
has been removed by surgery. Eligible patients have adenocarcinoma, a type of non-small lung
cancer, and must have 1 or more of the following characteristics: be female, be of Asian or
Pacific Rim descent and/or be a never smoker. The potential participant's tumor will be
examined for Epidermal growth factor (EGFR) mutations. EGFR is a protein that is
overexpressed in most non-small cell lung cancers. Some EGFR has been found to have specific
mutations and the participant must have one of these mutations in his tumor.
Erlotinib blocks this protein and may control tumor growth and increase survival. Previous
research has shown that erlotinib is most effective for people who have these specific
mutations in the EGFR.

Stanford is currently not accepting patients for this trial.For more information, please contact Lei Shura, 650-723-2312.

This multicenter, single-arm study will evaluate the efficacy and safety of Atezolizumab in
patients with PD-L1-positive locally advanced or metastatic non-small cell lung cancer.
Patients will receive Atezolizumab 1200 mg intravenously every 3 weeks as long as patients
are experiencing clinical benefit as assessed by the investigator, i.e., in the absence of
unacceptable toxicity or symptomatic deterioration attributed to disease progression.

Stanford is currently not accepting patients for this trial.For more information, please contact Lisa Zhou, 650-736-4112.

This research study is a Phase II clinical trial, which tests the safety and effectiveness
of an investigational drug to learn whether the drug works in treating a specific cancer.
"Investigational" means that the drug is still being studied. It also means that the FDA has
not yet approved afatinib for use in patients.
In this research study the investigators are looking to see if taking afatinib after surgery
works better when taken over a short period of time, compared to a long period of time.

This multicenter, single-arm study will evaluate the efficacy and safety of Atezolizumab in
patients with PD-L1-positive locally advanced or metastatic non-small cell lung cancer
(NSCLC). Patients will receive an intravenous dose of 1200 mg Atezolizumab on Day 1 of
21-day cycles until disease progression.

Stanford is currently not accepting patients for this trial.For more information, please contact Lisa Zhou, 650-736-4112.

This study will evaluate the safety, preliminary efficacy, and pharmacokinetics (PK) of
momelotinib (MMB) and erlotinib, as well as define the maximum tolerated dose (MTD) of
momelotinib (MMB) combined with erlotinib in adults with epidermal growth factor receptor
(EGFR)-mutated, EGFR tyrosine kinase inhibitor (TKI) naive metastatic non-small cell lung
cancer (NSCLC). Participants will be sequentially enrolled to receive progressively
increasing doses of MMB in combination with erlotinib. Escalation of MMB doses will proceed
to the MTD, defined as the highest tested dose associated with dose-limiting toxicities
(DLT) during the first 28 days of combined erlotinib and MMB treatment. There will be four
dose levels and each treatment cycle will consist of 28 days.

Stanford is currently not accepting patients for this trial.For more information, please contact Smriti Rai, 650-723-0270.

This randomized phase II trial studies how well erlotinib hydrochloride or crizotinib with
chemoradiation therapy works in treating patients with stage III non-small cell lung cancer.
Radiation therapy uses high energy x rays to kill tumor cells. Specialized radiation therapy
that delivers a high dose of radiation directly to the tumor may kill more tumor cells and
cause less damage to normal tissue. Drugs used in chemotherapy, such as cisplatin,
etoposide, paclitaxel, and carboplatin, work in different ways to stop the growth of tumor
cells, either by killing the cells, by stopping them from dividing, or by stopping them from
spreading. It is not yet known whether giving erlotinib hydrochloride is more effective than
crizotinib with chemoradiation therapy in treating patients with non-small cell lung cancer.

This is a multicenter, open-label, first-time-in-human study with a standard 3+3
dose-escalation phase in subjects with advanced solid tumors followed by an expansion phase
in patients with advanced solid tumors. An exploration cohort has been added to determine
the safety using Q4W dosing.

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie San Pedro-Salcedo, 650-724-1388.

The purpose of this study is to show that Nivolumab will improve progression free survival
in subjects with strongly Stage IV or Recurrent PD-L1+ non-small cell lung cancer when
compared to chemotherapy

Stanford is currently not accepting patients for this trial.For more information, please contact Smriti Rai, 650-723-0270.

This is the first human study to use X-396 (ensartinib), a drug being developed for
treatment of advanced cancers. The initial purpose of the study is to determine the largest
amount of X-396 that can be safely given to humans (the maximum tolerated dose). Once the
recommended Phase 2 dose has been determined, an expansion phase will assess the preliminary
anti-tumor activity of X-396 in ALK-positive non-small cell lung cancer. The study will also
provide early information on how the body handles the drug (pharmacokinetics) and on the
efficacy of X-396.

Buccal Versus Vaginal Misoprostol for Third Trimester Induction of LaborRecruiting

Approximately 22% of term pregnancies are induced. Misoprostol, a prostaglandin E1 analogue,
is a widely accepted induction agent, that has been proven safe and effective for induction
of labor. It stimulates both cervical ripening and uterine contractions, thus making it an
ideal induction agent for unfavorable cervices. Research has examined the pharmacokinetics
of different administration routes and effects on uterine contractility, side effects, and
safety. Vaginal misoprostol has been shown to be superior over oral administration however
patients often prefer a more tolerable route. Buccal administration has already been shown
to be as effective as vaginal misoprostol for cervical ripening and induction in both first
trimester and second trimester abortions. There is minimal research comparing buccal versus
vaginal for third trimester induction of labor. The investigators study is a prospective,
double blinded, randomized control trial comparing vaginal misoprostol and buccal
misoprostol in equal dosages of 25 mcg. The investigators seek to answer the question
whether buccal misoprostol is as effective as vaginal misoprostol for third trimester
induction of labor.

The purpose of this study is to compare the anti-tumor efficacy of oral single-agent
rociletinib, as measured by investigator assessment of the PFS, with that of single-agent
cytotoxic chemotherapy in patients with EGFR-mutated, advanced/metastatic NSCLC after
failure of at least 1 previous EGFR-directed TKI and at least 1 line of platinum-containing
doublet chemotherapy.

Stanford is currently not accepting patients for this trial.For more information, please contact Melanie San Pedro-Salcedo, 650-724-1388.

A research study to learn about the biologic features of cancer development, growth, and
spread. We are studying components of blood, tumor tissue, normal tissue, and other fluids,
such as urine, cerebrospinal fluid, abdominal or chest fluid in patients with cancer. Our
analyses of blood, tissue, and/or fluids may lead to improved diagnosis and treatment of
cancer by the identification of markers that predict clinical outcome, markers that predict
response to specific therapies, and the identification of targets for new therapies.

Projects

Model of Care: Integration of palliative care into cancer care using a human centered design approach

We will be codeveloping a new model of primary and specialist palliative care delivery at Stanford Cancer Institute incorporating the values of patients, family members and clinicians. New outcome metrics will be developed that incorporate the values of key end users and stakeholders.

Publications

All Publications

Abstract

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Abstract

With the growing and evolving role of palliative care in oncology, we examined how supportive care (SC) and best supportive care (BSC) are implemented in clinical trials when used as a comparison treatment arm.We conducted a systematic review of the literature for clinical trials published between 1980 and 2012 in which systemic anticancer therapy was compared with an SC-only arm and compared SC implementation with World Health Organization (WHO) published guidelines.Our search identified 189 articles, 73 of which met our inclusion criteria with the following cancer types: 29 lung, 7 colorectal, 6 pancreatic, 5 gastric and 26 others. Fifty-five studies (75%) provided some definition of SC, and 48 studies (66%) used the term BSC. Twenty-one of the 55 studies that provided a definition described the use of palliative therapies as being 'at the discretion of the treating physician' without standardization. Only two studies provided SC that incorporated routine physical, psychological and social assessments including rapid referral to SC specialists. SC interventions most commonly included analgesics (47%) and radiotherapy (44%). Trials using the term BSC versus SC were more likely to include blood transfusions (P = 0.002) and antibiotics (P = 0.033), but less likely to include steroids (P = 0.05) and palliative specialists (P = 0.047).The implementation of SC in clinical trials in this systematic review is highly variable. The vast majority of the studies did not meet the WHO guidelines on SC because palliative care therapies were not recommended or integrated into care. Future clinical trials utilizing a SC intervention arm should define these interventions in a standardized approach that meets current guidelines such as the WHO recommendations.

Abstract

Leptomeningeal carcinomatosis (LM) is a severe complication of non-small-cell lung cancer (NSCLC) historically associated with poor prognosis. New chemotherapeutic and targeted treatments could potentially affect the natural history of LM.Patients with a pathologic diagnosis of NSCLC with LM treated at Stanford between 2003 and 2011 were identified via institutional databases and medical records. LM was defined by cerebrospinal fluid (CSF) that was positive for malignant cells or by LM enhancement on magnetic resonance imaging with gadolinium contrast. Retrospective, landmark analyses were performed to estimate survival. Statistical analyses were performed using SAS Enterprise Guide, version 4.3.LM was identified in 30 patients. All cases were adenocarcinoma; 60% of patients had a known or suspected driver mutation. The mean age was 58 years. Of the 30 patients, 67% were women; 70% were nonsmokers; 27% initially presented with LM; 84% received systemic treatment at or after development of LM; and 53% of these patients received modern systemic therapy for their LM, defined as a regimen containing pemetrexed, bevacizumab, or a tyrosine kinase inhibitor. Mean overall survival after LM diagnosis was 6 months (95% CI, 3-12). Patients who received modern systemic therapy for LM had decreased hazard of death (hazard ratio [HR], 0.24; P = .007).In this retrospective, single-institution analysis, median survival with LM was higher compared with historical experience. Patients who received modern systemic therapy for their LM had particularly good outcomes. These data provide evidence for improving survival outcomes in the modern treatment era for this difficult-to-treat complication.

Abstract

Palliative cancer care is the integration into oncologic care of therapies that address the issues that cause physical and psychosocial suffering for the patient and family. Effective provision of palliative cancer care requires an interdisciplinary team that can provide care in all settings (home, inpatient, and outpatient). There is clear evidence for improved outcomes in multiple domains-symptoms, quality of end-of-life care, provider satisfaction, cost of care-with the integration of palliative care into cancer care. As a result, there are now guideline-based recommendations for incorporating palliative care into cancer care. Unfortunately there continue to be barriers to effective integration; these include gaps in education and research, and a cultural stigma that equates palliative care with end-of-life care. These barriers will need to be addressed in order to achieve seamless palliative care integration across the continuum of cancer care for all patients and their families.

Abstract

Non-small cell lung cancer (NSCLC) is traditionally classified histologically, but until recently, the histologic subtype has had little impact on the selection of therapy. Drugs such as pemetrexed and bevacizumab are indicated for specific NSCLC subtypes, and this type of stratification represents the first step toward individualizing therapy in NSCLC. Beyond histologic features, the status of molecular targets, such as the epidermal growth factor receptor (EGFR) gene, has been shown to correlate with response to treatment with EGFR tyrosine kinase inhibitors in patients with relapsed or refractory disease and in the first-line therapy setting. New therapies targeting the EGFR and other molecular aberrations are under way to help define specific subsets of patients responsive to certain molecularly targeted treatments. The role of pathologists in guiding treatment decisions will increase because molecular profiling, together with pathologic and histologic analysis, represents the future of personalizing medicine for patients with NSCLC.

Abstract

Lung cancer has reached epidemic proportions in women, and is now the most common cause of cancer death among both men and women in the United States. While smoking rates have declined marginally in women, the rising impact of lung cancer in women may imply that women are at higher risk from carcinogens secondary to underlying factors related to sex. These factors include differences in female physiology such as bronchial responsiveness and airway size, sex-based differences in nicotine metabolism via the cytochrome p450 system driven by hormones, and differences in DNA repair capacity, as well as the evolution of cigarettes. These hypotheses will be explored in depth in this article.